Personal Trainer Client Intake Form

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Name*

First NameLast Name
Birth Date*

MonthDayYear
FemaleMale
Height*
cm/feet & inches
Weight*
kg/stone
Phone Number*

Area CodePhone Number
Email*
example@example.com
Are you taking any medications? If yes, please list below.*
Do you have any diagnosed/on going health problems?*
Do you have any injuries? If yes, please list below.*
Low-proteinLow-carbHigh-carbsVegetarian/VeganNo special diet
What does a typical day of eating look like? Include estimate timings of meals/how many meals.*
Do you take any supplements, if so what are they?
YesNo
What is your daily activity level?*

1

2

3

4

5

1 is None, 5 is High
What is your daily stress level?*

1

2

3

4

5

1 is Low, 5 is High
3-5 Hours5-8 Hours8+ Hours
0-1 Times a week1-2 Times a week2-4 Times a week
Improved general healthImproved enduranceIncreased strengthIncreased muscle massFat lossOther
12 Weeks6 Months12 MonthsFor as long as I can
Why is it do you think that you are struggling to achieve these goals? Lack of motivation? Lack of accountability? Struggling to train accordingly? Etc.
Appointment*
Signature*
Should be Empty:

Looking For A Personal Trainer?